Experts Address Concussion Injuries, Treatments, and New Technologies in Pittsburgh

The hard-hitting topic of concussions is resonating throughout Pittsburgh. From the initial discovery of the consequences of head trauma from an autopsy on former Pittsburgh Steeler Mike Webster, to the dramatic research in prevention, the realization is that concussions cause long-term damage. In our initial research, we found alarming information about what happens to the brain when it is concussed. As we progressed, we saw an urgent need to bring awareness to the injury, disease, and prevention. Read on about the impact being made right here in Pittsburgh. — C.T.

By Andrea Bosco, Rachel Jones, Liz Petoniak, and Christine Tumpson

Photography: Kassie Jackson.

“Most players have had concussions. When I played, you got your bell rung and they gave you smelling salts. I think one of the good things now is how much doctors have learned about concussions versus when we played. The research on the effects of concussions is a positive. I think it’s really important, and I’m glad to see the NFL is doing tests before they go back on the field. You always want the best interest of the player and quality of life after retirement.” — Mel Blount, former Pittsburgh Steeler, Mel Blount Youth Home

Photography: Duane Rieder.

“We, as a baseball family, are very much aware of the importance of helmets in our game. It is an obvious need for the batter and the catcher, but in recent years MLB has extended the focus to the first and third base coaches, as well as the pitchers. Helmets go a long way toward the prevention of concussions in baseball.” — Clint Hurdle, Pittsburgh Pirates manager

Photography: Shadyside Eye Associates.

“Timing would be the primary factor in diagnosing a concussion. The visual system is extremely vulnerable to traumatic brain injury, or concussion, because nearly half of the circuits in the brain are involved in vision. The most important factor in diagnosing a concussion is to diagnose the injury as soon as possible to prevent a second, repeat concussion to already fragile and injured brain tissue, which is what frequently happens in sports and can lead to long-term damage. Testing visual function on the sideline rapidly and reliably is crucial — for example, with The King-Devick Test — and we are looking at visual memory, visual processing, the ability to track objects, and pupil abnormalities.” — Dr. Alicia Telega, Shadyside Eye Associates

Photography: Michael Fornataro.

“Football is a contact sport, and it’s not for everyone. As athletes, we all know what we signed up for. With contact, concussions are just a part of the game. It’s a known risk we take going into it. So, I don’t know that there is a lot we can do to prevent concussions. As a league, we can only try to better educate players on what to do when you get a concussion. And, I think the league and the medical community are doing a better job at educating folks on the proper concussion protocol. As long as you have violent contact, you’re not going to be able to completely prevent concussions. That’s football. With kids, I basically try to stress the importance of how to take a hit, how to hit others, and what to do when you get a concussion. It’s more important that you don’t get that second concussion too soon after the first one and that you take enough time to completely heal from any head trauma.” —Hines Ward, former Pittsburgh Steeler

INJURY | The Evolution of TBI

Rocky Bleier. Photography: Lindsay Dill.

From a player’s standpoint, former Pittsburgh Steeler Rocky Bleier says the recognition and treatment of concussions has greatly improved over the years. The former Pittsburgh Steeler recalls the days when players would be labeled as “seeing stars,” then asked to count how many fingers were held in front of their faces. “People didn’t necessarily understand, and there wasn’t much research being done or it wasn’t accessible to the general public,” Bleier says. “Even if there were voices, they were very quiet voices.” Traumatic brain injuries (TBIs) became more prominent once the connection between concussed athletes and suicide, plus their effects on our veterans, received more exposure. From that increased exposure came increased researching, causing the innovated technologies to trickle down from professional sports to college to high school. Baseline testings have become the new standard — so concussed athletes can be compared to normal versions of themselves, not a subjective scale. Then, appropriate rest can be scheduled and the likelihood of sustained injuries due to constant trauma can decrease. Bleier points out that continuing to play contact sports can affect your life, but so does choosing to go for a ride in a car. It’s all about making smarter, better decisions. “Why do we watch football?” Bleier asks. “We like the hits. Our gladiators are in that form of professional sports. Football is a collision sport; you can’t take that factor away. What you can do is be aware of it and practice better techniques.” — R.J.

One of the most important things one must do being officially diagnosed with a concussion is to rest. It takes time for symptoms of a concussion — some include ringing in the ears, nausea, headaches, or disorientation — to subside. “Years ago, those who suffered a concussion would be discharged and sent back into activity once the symptoms resolved,” says Frank Velasquez, ATC, CSCS; former Pittsburgh Pirates strength and conditioning coordinator; and current co-owner of VESLA 360 Sports Performance & Physical Therapy. “Today, concussion awareness is at an all-time high, and we know so much more. There are pre-season brain performance and post-concussion exertion tests that are used to help determine if the concussed person is ready to return to full status.” Here’s how the Post-Concussion Exertion Test administered by the Certified Athletic Trainers at VESLA 360 works:

PHASE 1: The concussed person is taken through a “light activity” exercise routine. Objective measures, such as heart rate and blood pressure, are taken and recorded. The participant will also provide subjective comments on any reoccurrence of symptoms. The next day, a VESLA 360 specialist will check in on the patient. If he or she has no reoccurrence of symptoms, Phase 2 will begin the following day. If there are symptoms present, time is allowed for the symptoms to subside, and Phase 1 is repeated.

PHASE 2: The next step is similar to Phase 1, but with a higher level of intensity and exertion. Balance and Agility drills are added. Again, the participant can move on in two days, only if the phase is passed.

PHASE 3: Similar to Phase 2, a higher level of intensity and exertion is reached in Phase 3, and sports specific movements are added. Once the patient completes and passes the third phase and is signed off by VESLA 360, he or she returns to the referring physician to be released from care and allowed back into activity. It is advised that patients start with a “limited” status, so they can ease back into full, unrestricted activity. “There is a team of qualified professionals that have a say in the patient’s ‘return to play’ because of the dangers of going back to playing at full status before a concussion is fully resolved,” Velasquez says. “Going back too soon and suffering another concussion can really be a bad situation.” Velasquez sits on the North Allegheny Youth Sports Safety Committee where he helps to bring more concussion awareness and education to coaches, parents, and athletes; and his exercise programs are implemented to help reduce the risk of suffering a concussion. — R.J.

The University of Pittsburgh School of Medicine researchers recently unveiled that white matter brain abnormalities in some patients with depression disorders closely resemble abnormalities found in patients who have had concussions. White matter in the brain is comprised of fibers that allow different parts of the brain to communicate with one another. While examining MRI scans in 74 concussion patients from 2006-2014, Dr. Saeed Fakhran used diffusion tensor imaging to see if the white matter was injured, decreasing connections in the brain and post-concussion symptoms. “Finding such similar injuries in (mild traumatic brain injury) patients with depression and major depressive disorder may suggest a common pathophysiology in both traumatic and non-traumatic depression that may help guide treatment,” the assistant professor of radiology at the University of Pittsburgh says. “If we can prove a link, or even a common pathway, between post-traumatic depression and depression in the general population, it could potentially lead to effective treatment strategies for both diseases.” — A.B.

“Concussions are such a unique and different condition because they are detected by the event,” says J. Howison Schroeder, president and CEO of Neuro Kinetics, Inc. “It’s not like there’s a thermometer that measures if you had a concussion or not.” To revolutionize concussion diagnosis, Neuro Kinetics, Inc. developed the I-Portal®. The high-end digital video technology tracks the reflexes of the eyes, which are then compared to results from non-concussed controls. The objective tool determines neural function, improving concussion diagnosis. Impressed by the innovation, the National Football League, GE Ventures, and Under Armour awarded a $500,000 grant to the University of Miami Miller School of Medicine, the University of Pittsburgh School of Medicine, and Neuro Kinetics, Inc. as part of the Head Health Challenge II Initiative. One of only seven groups to receive a grant, I-Portal® PAS (Portable Assessment System) will be presented again later this year, with the hopes of earning an additional $1 million grant and FDA approval. “We do believe we are on track to be the first FDA-cleared indication for concussion,” Schroeder says. “Having been around for 30 years, we have a much more complex and elegantly woven fabric of tests and analysis to our solution to concussions.” An FDA approval would lead to I-Portal® PAS being available in primary care offices, sports clinics, locker rooms, and military hospitals. Essentially “a laptop and big goggles,” the mobile tool will get athletes and military personnel diagnosed and quickly on their way to proper treatment. “Working with the NFL, our key right now is to help the professional football players,” Schroeder explains. “But it’s the high school kids that we need to help. It’s the soldiers. If we can make sure we can manage them well, then I think we’ve done our job.” — R.J.

Dr. Marcel Just is world-famous for using brain imaging to understand how brain processes underpin various types of human thought. His focus on brain sciences now commands full attention at Carnegie Mellon University, which recently launched BrainHub to build from its research excellence in psychology, computer science, and computation to solve real-world problems. Recent research from the esteemed school’s Center of Cognitive Brain Imaging illustrates the resiliency of the human brain, which can revert to alternate systems of functionality after trauma, as evidenced by the readings of the MRI scans of the study’s participants. “It is now clear how the brain can naturally rebound from injuries and gives us indications of how individuals can train their brains to be prepared for easier recovery,” says Dr. Just. “The secret is to develop alternative thinking styles, the way a switch-hitter develops alternative batting styles. Then, if a muscle in one arm is injured, they can use the batting style that relies more on the uninjured arm.” The study concluded that when one brain area loses functionality, a “back-up” team of secondary brain areas activates. — C.T.

For more information, visit the Center for Cognitive Brain Imaging at Carnegie Mellon University’s website at ccbi.cmu.edu.

PREVENTION | Concussion Education at Central Catholic High School

Central Catholic High School senior John Petrishen. Photography: Barry Myers.

Central Catholic High School Assistant Principal for Student Affairs Andy Macurak formerly served as an athletic trainer at the UPMC Center for Sports Medicine. “Concussions were the worst part of my job,” he says. “There was always such a gray area with signs and symptoms. Now, they’re treated and recognized much better.” In Macurak’s sports medicine class, he talks to students about real-life situations and concussion stories in the news. “It is an eye-opener,” he says. “With contact sports, parents and even kids are scared, but we also give our children keys to the car and let them ride bikes. Sports are probably safer than they’ve ever been.” If a student-athlete exhibits symptoms of a concussion during a game or practice, he is pulled from all activity. “Mismanagement is the problem with concussions,” he adds. “They have to be treated properly.” Central Catholic’s athletic equipment, including helmets, is re-certified yearly, according to Macurak. “Everyone is searching for that Holy Grail of helmets that can prevent concussions, and more money is being put into equipment design than ever before,” he says. Macurak feels Western Pennsylvania and the UPMC Center for Sports Medicine is on the cutting-edge of concussion technology. “I think the awareness is a good thing.” — A.B.

Roberto Clemente Jr. actively sits on the board of RC21X, an innovative web-based tool, backed by advanced science and research, to help people take personal responsibility for their brain health. Its name comes from his father, former Pittsburgh Pirate Roberto Clemente, as its mission aims to mimic No. 21’s humanitarian vision and legacy. RC21X CEO Clarence Carlos, along with Michael Hauser, Mark Cavicchia, Paul Chirgott, and three other members of the RC21X executive team, founded the company in 2013. They recruited renowned researchers from the fields of human and cognitive performance, celebrated medical practitioners, experienced game and software designers, and successful business and organizational administrators to design the organization’s Thermometer for the BrainSM. The goal was to make an engaging, simple, game-like platform, in order to empower people to monitor their brain performance. Having suffered 10 to 12 concussions before entering high school, Clemente Jr. is particularly passionate for this technology. “I stop breathing thousands of times a day — I’m lucky to have oxygen in my brain,” he says. The 12-minute session uses standardized, simple procedures that are fun and doable by children and adults. The activities measure your Brain Performance Profile (BPP) and then monitor it to better understand and evaluate issues that may result in fluctuations possibly caused by a sports-related injury, the start of a new medication, or concerns about substance abuse or sleep deprivation. “It’s a neuro-cognitive, neuro-monitor test,” says Clemente Jr. “Concussions are a very small part of what this tool does — it’s about brain health as a whole that can identify signs of dementia, Alzheimer’s, and ALS. It’s the only tool of its kind. It’s important to have this information because you never know what life will bring you.” — A.B.

2nd Skull Founder and CEO Federico Olivares, his wife Stephanie, and their two children, Fico and Gaby. Photography: 2nd Skull.

When it comes to protecting the brain against injury, any little bit helps. While improvements in helmet safety are in the works, head protection caps may provide more immediate defense. One locally headquartered company, 2nd Skull, is leading the charge. Motivated by the frustration and fear he felt watching his own son sustain a head injury while wearing a helmet, 2nd Skull Founder and CEO Federico Olivares launched his brand of protective athletic headwear in 2012. The 2-millimeter-thick caps, worn underneath a helmet, and headbands, worn during athletic activity that typically does not require a helmet, are made in the U.S. with a protective material known as Poron XRD. Leading sporting good companies such as Bauer, Schutt, and Rawling’s also use Poron XRD, which is comprised of flexible soft urethane molecules that harden under pressure for impact protection. Olivares says, “Our products really look like and feel like a stylish headband or cap versus a lot of other products that are bulky and heavy. We want to make sure that our products are comfortable and not distracting the athletes.” But, most importantly, the caps are proven to alleviate impact. Test results completed at an independent, third-party lab show they can “add up to 35 percent more impact protection to a standard sports helmet.” Olivares explains that the lab utilized the same testing techniques that professional football helmets undergo, showing that the caps can reduce impact by up to 26 percent when worn underneath football helmets and by as much as 60 percent when worn underneath for skiing, snowboarding, BMX, cycling, and skateboarding helmets. Olivares attributes the latter finding to the fact that helmets worn for those sports are not held to the same strict safety regulations that other sporting helmets, such as football and hockey are. Currently, 2nd Skull has been testing its products on athletes at local high schools and colleges, and is working to confirm brick and mortar retailers for his product in 2015. For now, you can purchase 2nd Skull caps and headbands via its retail website. — L.P.

A new start-up called VICIS, which means “change” in Latin, is gunning to bring transformative technology to the football helmet making industry, which the company laments has changed very little in the past 50 years. Beloved former University of Pittsburgh football player, Bill Osborn (many may remember him as the only player to letter in three varsity sports at the university since Mike Ditka), who went on to play in the NFL, AFL, and WLAF, has become passionately involved in the project as an investor and advisor. He says, “The goal is to make it the best looking, the best fitting or feeling, the highest performing, as well as the safest helmet using new technology. What we hope will be different about this helmet versus helmets players are wearing today is how it will potentially address the forces likely to cause concussions and head injury.” In conjunction with the University of Washington and a team of neurosurgeons, mechanical engineers, public health experts, and innovative business experts lead by CEO Dave Marver, they hope to have a prototype ready soon. VICIS took a huge step forward in their mission to achieve this by recently receiving a $500,000 grant (with potential to win an additional $1 million) from the National Football League in conjunction with GE and Under Armour, as a part of the Head Health Challenge II Initiative. To date, the company has raised more then $2 million in capital for this project. “With all of my experiences surrounding concussions and football, along with my long friendship with CEO Dave Marver, we thought this was a perfect opportunity for us to work together,” explains Osborn, “I truly want to do something that will be impactful and really make a difference in the lives of people who are involved in athletics, and in the lives of my children. I have two boys who all play football. Fifty percent of parents [in the U.S.] don’t want their children playing football [according to a recent poll conducted by Bloomberg Politics], so this impacts people’s everyday decisions. And, that’s why there’s so much passion behind it to really try to make a difference.” In the long term, VICIS hopes to be able to create safer helmets for other sports outside of football as well. — L.P.

Drs. Mark Lovell, Ph.D., Joseph Maroon, M.D., and Michael “Micky” Collins, Ph.D., co-founded ImPACT Applications, Inc., in 2002, however, the technology was developed in the 1990s based on initial research with the Pittsburgh Steelers. The science behind ImPACT was developed in response to requests for neurocognitive testing from the NFL to help determine safe return to play. In 1997, the ImPACT Concussion Management Model was first put into use and its programs have been widely used in the NHL, NFL, and other professional sports and collegiate ranks. “Our program is now available in 15 languages, and since 2000, we’ve tested 8 million kids,” says Lovell. He and his team are furthering technology, making the test available at users’ fingertips. “About three years ago, I started developing a test for the iPad geared for children ages 5 through 12,” he says. “We developed a game-like interface that kids really enjoy.” The app is being researched in a multi-center study and will be available for download this year. Collins is also involved in researching concussions in Special Olympics. He says, “No one could ever evaluate Special Olympians because of intellectual disabilities, and that is changing. We’re very excited about that.” Collins feels passionately about making this technology available to all, which includes everyone from pediatricians to sports professionals, and beyond. “Fifteen years later, we’re at the point where we can do just that. The technology is readily available, inexpensive, and it’s standard now.” — A.B.

Robert Morris University men’s basketball player Lucky Jones. Photography: Robert Morris University.

Of the 3.8 million concussions that occur every year, 300,000 are due to sport. At Robert Morris University, head athletic trainer Mike Vittorino implements preventative measures – including practicing better technique on the field, and educating players on signs and symptoms – to enable better treatment of injuries. In 2010, the NCAA issued a concussion policy that required a written protocol be put in place. “We already had one, but we updated it at that time,” Vittorino says. “Our athletes sign statements saying they must report concussion symptoms. We watch practices daily and in the instance of a suspected concussion, we consult our team physicians for further evaluation.” If a concussion is diagnosed, the athlete is removed from activities and placed in the post-injury plan of care per the RMU Concussion Management Protocol. While tracking symptoms and comparing the athlete to his or her baseline during this activity-free time, the athletic trainers at RMU also help with the student’s academics. “There can be some cognitive issues during a concussion,” Vittorino explains. “We talk to the professors and make any recommendations to help them heal as quickly as possible.” By working with the student athletes on the university’s 16 NCAA Division 1 teams, RMU’s athletic trainers work to keep the fields a safer place. — R.J.

Aside from looking at the brain itself, concussed patients should also seek care for the upper neck/base of the skull. Dr. Ian Bulow, an upper cervical chiropractor at Revive Upper Cervical Chiropractic, recommends patients seek treatment within 72 hours of a head injury of any kind. “Not only is it important for the long term effects of the neck, but the brain as well,” he says. His specialty is the Blair Chiropractic Technique, a very gentle and precise manual procedure that’s designed to restore proper alignment of the head and neck. The realignment can happen in one session or over a period of sessions, depending on the extent of the injury. “I typically see improvements within 6-12 weeks of care, and we currently have a very high percentage of recoveries in concussion cases,” Bulow says. “The sooner we see the person, the better the outcome generally is.” The amount of soft tissue damage often dictates the recovery time, but many standard MRIs do not show the finer details of concussion-caused damage. With custom, digital X-rays, Bulow can look at individual joints in the spine and deliver a procedure without any turning or twisting of the neck. He also utilizes a special form of thermography to evaluate the deeper parts of brain function. “With every case that gets better, I become more and more convicted to raise awareness of this sort of procedure,” Bulow says. “This is not about neck or back pain. This is about restoring alignment and brain function. This is about restoring someone’s life.” — R.J.

For the last 20 years, Dr. Edward Snell has worked on developing a rigorous and comprehensive program for concussions. As the director of primary sports medicine at Allegheny Health Network and the head of Allegheny General Hospital’s sports medicine concussion program, Snell’s clinical and research roles have earned him spots on Major League Baseball’s Concussion Committee and the PIAA Sports Medicine Advisory Board. At Allegheny Health Network, his focus is on establishing an effective way to manage concussions. “By working with some of the major centers across the country — The Cleveland Clinic Foundation and The Johns Hopkins Hospital — we’ve been trying to institute programs that will get people back to their activities in a quicker fashion,” Snell says. Imaging techniques can hone in on specific areas of the brain that have been injured, so they can be rehabbed. Providing stimulation — or protection, depending on the degree of the injury, helps the isolated neuron operate more efficiently and effectively. “Some people never recover neurologic function, but that depends on the injury and the person’s age,” Snell says. “The youngest patient I’ve had was four or five, and the oldest was 99 or 100.” Caring for 25-30 high schools, several colleges, the Pittsburgh Pirates, USA Rugby, USA Olympic Committee, the Pittsburgh Riverhounds, and patients across the country, Allegheny Health Network is constantly searching for the latest technologies and tests to implement. “Science has allowed us to change things at much more microscopic levels, allowing us to understand the path of the injury itself and how it’s going to impact the brain,” Snell says. “The brain controls everything, so understanding the impact of that from concussions will allow us to have better prevention and treatments for it in the future.”

The latest innovation from Allegheny Health Nework is the C3 Logix test. The program measures reflexes, reaction times, and symptoms on the subject when he or she is healthy, keeping an electronic record of it all. If a head injury occurs, the test can be taken again and compared to the baseline results. Chris Parker, an athletic trainer at Allegheny Health Network, says participants rate their symptoms, memorize words to be repeated minutes later, and take on the balance evaluation. “The Balance Error Scoring System is unique to this concussion test,” Parker explains. “It measures static and dynamic vision, reaction time, and concentration.” As Carlynton High School sophomore Jake Seitz demonstrates, the exam starts by strapping the C3 Logix tablet to the participant’s back. With his eyes closed, the tablet asks Seitz to stand with his feet together, with one foot in front of the other, and on one foot at a time — each for a set period of time. Any sway in posture or shift in balance is measured, and used to thoroughly assess brain function. — R.J.

Each year in Pennsylvania, nearly 4,000 children sustain moderate to severe traumatic brain injuries that require hospitalization and more than 20,000 children sustain concussions. Realizing the gap these children were experiencing during the transition between the hospital or rehab center and returning to school and their normal, everyday lives, the Pennsylvania Department of Health created BrainSTEPS (Strategies Teaching Educators, Parents, and Students) Brain Injury School Re-Entry Consulting Program. The BrainSTEPS Program began in 2007, and is implemented by the Brain Injury Association of PA. BrainSTEPS is currently funded by the PA Department of Health and the PA Department of Education, Bureau of Special Education through the PaTTAN network. Other states look to Pennsylvania as a model for this free service that assists school districts in creating educational plans for students following any type acquired brain injury, whether it’s from a concussion, a car accident, stroke, or tumor. Says Statewide Program Coordinator Brenda Eagan Brown, “The program really brings together the students’ doctors and medical team with their parents and school to form a partnership, that keeps everyone on the same page. Through the educational Intermediate Unit training, schools feel they have the support from BrainSTEPS to implement the re-entry process and the tools to continue to monitor the students’ progress.” The process begins with a referral following the brain injury. Once the student is well enough, BrainSTEPS sits down with the parents, school administrators, and teachers to put academic accommodations in place immediately that are specifically tailored to the individual students’ needs. Examples of accommodations may include: no testing during the first few weeks, a workload reduced by 50 percent, cutting repetition in homework, and breaks built into the school day. “When the brain is initially injured, it uses all of its energy to recover and thinking too hard during this timeframe could prolong the students’ recovery. Academic accommodations should be in place in all classes to keep a student below their symptom threshold, because if a student has to ask for an accommodation (such as a break) the student probably already has a symptom, and then it’s too late,” says Eagan Brown. “BrainSTEPS has created 800 Return to Learn Concussion Management Teams in just the past two years, and we are the only state in the U.S. to do something like this.” BrainSTEPS continues to monitor students after their injury until graduation. — L.P.

Roughly 17,000 patients visit the UPMC Sports Concussion Clinic every year, including an average of 85 patients per day. “We see patients as young as 4 years old, up to about 65, whose injuries are sport-related, work related, car accidents, and slip-and-falls,” says neuropsychologist Erin Reynolds, Psy.D. “Each patient gets a unique treatment plan tailored to issues related to six different areas, each receiving researched and clinically proven therapies.” She says the beginning stage focuses on rest from both a cognitive and physical perspective. “We want them to let their brain heal,” she says. “But, we take an active approach. We let the injury breathe for about a week and make sure they have a regulated schedule in terms of sleeping, hydration, and managing stress well.” Reynolds and her team use vestibular rehabilitation for patients with vision issues and dizziness, and eventually increases to physical exertion, working with physical therapists, athletic trainers and primary care sports medicine physicians. “Our research has shown that if an athlete experiences dizziness immediately following an injury, they may have a more complicated recovery,” she says. “We look for symptoms out of the ordinary —sensitivity to light or noise, fogginess, nausea. And, we stress the comprehensive evaluation be done by a concussion specialist.” Reynolds is confident in the general public’s recent response to concussions. “We’re taking things a lot more seriously now,” she says. “Across all levels, coaches are really being taught to recognize the signs and symptoms of concussions and using baseline testing, usually in the form of the ImPACT test.” Reynolds stresses the importance of taking the complex injury seriously because recovery can be that much quicker. “Today, people are thirsty for more information, which has changed from 20 years ago.” Last month, the UPMC Sports Medicine Concussion Program launched rethinkconcussions.com, a website packed with information, including local patient stories, sports concussions in the news, and new testing technology. “It is a wonderful site for parents, educators, and patients.” — A.B.